Preschool Physical Activity Guidelines
The World Health Organization has a goal to implement physical activity in preschool improving motor competency in all children; this is associated with a higher level of physical activity later in childhood and reduces the risk for obesity. This effort is a response to the research showing that sedentary behavior and obesity is the fourth leading cause of death in the world today. Teens today are the first generation in many years that is not predicted to live longer that their parents!! As musculoskeletal experts we are part of the team promoting this and making information available to our patients.
Acquiring motor skills in infancy and at a minimum in preschool is important for encouraging physical activity throughout childhood and into adulthood. Motor skill training should be sequential and age-appropriate with a focus on performing them equally well from the right and left sides. The recommendation is to incorporate these skills into the preschool environment so all children gain proficiency in these areas. This should be done with games and the setting should be fun.
Motor skills on the floor are the starting point and included in this is getting up and down from the floor. Rolling to both right and left from stomach and back is important and can be made to be a fun exercise. Children having difficulty can be encouraged to start by looking to the right, turning the head to the right and then roll the body to the right. This integrates vision, balance and neck movements. Rolling back and forth from head to tail is also a skill to be mastered and with age, finding balance can be added. Using the concept of crawling in the pattern of an eight, and then crawling in the opposite direction integrates the both hemispheres of the brain.
Lying and rolling
Crawling and kneeling
Climbing
Bear walk
Sitting, standing, walking
Transitional positions

The next step is to train fundamental gross motor patterns which provide the foundation for complex movement strategies. Again as age and skills advance, training from both the right and left is important. Starting early on to walk to day care or school is a goal for children. Starting the day by being active increases the level of physical activity for the entire day.
• Throwing
• Catching
• Kicking
• Bouncing
• Hopping
• Skipping
• Jumping
• Running

As children grow and develop, play activities can be encouraged which improve gross motor skills. Again, making the active transport to school a game can be a way to incorporate play into a daily active routine.
• Coordination
• Endurance
• Speed
• Strength
• Flexibility

The recommendations for school age children are to be moderately but mostly vigorously active for at least one hour total a day. During moderate to vigorous activity it is difficult to talk Other activities during the day should include climbing, running, jumping and hopping. Sitting inside during the day should be limited. Screen time should be less than 2 hours.
Recent research supports targeting the school as a modifiable environment for increased physical activity, reaching particularly those who are less active. The strategies employed are active transport to school, physically active teaching methods, activity breaks, active homework and active classroom settings. Organized activities after school should be promoted as well as increasing the amount of physical education classes. This has been promoted in a community in Finland and it is the only place in the world where the trend of obesity has been reversed in all ages.
Let’s work together to promote a more active school and work environment and a healthy lifestyle.

pad nacke

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In children the size of the head is proportionally larger in reference to the body until puberty. Injuries sustained to the head and neck in infancy will affect a different area of the spine than during later childhood. The weight of the head is a strain on the neck. With that said a key message for children is to reduce strain on the neck by avoiding looking down for extended periods of time. We are seeing a rise in the incidence of screen related neck problems in children and adolescents which in Swedish is called ”Padnacke”. The message here is to keep screens at eye height, observe how your children use the different media and help them find a position where the sit up straight and have their head over their shoulders, gaze straight ahead. It may a help to use pillows in the lap to rest the arms on to raise screen height so the neck is not under strain. Check out the picutres on this site under ”ergonomi”. Another group of children who experience neck pain are those who are avid readers, play instruments and/or have prolonged static activities with their arms stretched out and unsupported. Sitting properly at a desk which is ergonomically adapted for the size of the child is important as well when doing homework. We recommend using the TV for films to reduce static strain on the eyes and the neck. Besides the neck, eyesight in children has been shown to be affected by prolonged periods of time looking at screens. Children are not looking using the eyes to look up and away nearly as much which has resulted in an increased incidence of myopia. The most vulnerable to neck pain are those who have had an injury early on to the head or neck. They tolerate less well when the neck is bent forward for sustained periods of time, over books or a screen. Good ergonomics at home and in school are important, but reducing screen time and increasing physical activity is critical for long-term optimal health of children.

A recent study published by the journal, Spinal Deformities, discovered a high prevalence of vitamin D deficiency in adolescents with scoliosis who are meant to undergo spinal surgery.

A total of 217 adolescents with either neuromuscular or idiopathic scoliosis were included in this study. All patients were scheduled to undergo either spinal fusion or initial growing rod placement surgery. Prior to the operation, the researchers recorded data regarding gender, age, body mass index, race, scoliosis type, spine surgery procedure and season of the year. Additionally, all individuals had serum blood draws in order to determine vitamin D status.

This is what the researchers found:

Approximately 75% of the participants were considered vitamin D deficient (<20 ng/ml; <50 nmol/l).

African Americans were more likely to be vitamin D deficient than Caucasians (p < 0.0002).

Those who were preparing for spinal fusion also experienced a greater risk of deficiency compared to those undergoing an initial growing rod placement (p < 0.03).

Low vitamin D status was most common during winter compared to any other season (p < 0.005).

Those with neuromuscular scoliosis had significantly higher vitamin D levels compared to those with idiopathic scoliosis (p < 0.0002).

The researchers concluded,“Low [25(OH)D] levels are reported in pediatric patients with scoliosis preparing for corrective spinal surgery. Population subsets most at risk for deficiency in this limited study include African American children, those presenting for spinal fusion surgery, and patients admitted in winter season.”

Scoliosis is defined by having abnormal curves in the spine. It can be a curve side to side forming an “S” when both the mid back and low back are involved, or a “C” curve when just the upper or lower spine is involved. Scoliosis is also used when there are excessive curves front to back. A kyphosis describes a strong curve in the mid back while excessive lordosis describes a strong sway back curve in the lower back.

Scoliosis can be functional or structural. A functional curve is a curve that is due to a condition and can be corrected. An example of this is a short leg which causes a tipping of the pelvis and a resultant scoliosis of the spine. A scoliosis from the bottom up.

A structural curve is one due to the way the spine and skeleton develops. There can develop during different time frames

Some curves start inutero when the developing fetus is positioned in a way that allows for uneven development of the cranium and face (plagiocephaly and unilateral microcephaly), and eventually a torticollis. This is called infantile scoliosis and there is an increased risk for hip dysplasia in these infants. This left untreated can result in a scoliosis. Some infants, those in a breech position or facial or brow presentation at birth can have asymmetry between the front and the back of the body. They usually have the head in a strong position of extension (looking at the ceiling), arms back, difficulty lying on the stomach. Besides physical treatment of the joints, ligaments and muscles, it is critical for the parents to learn how to train with the infant. Babies that are asymmetric already inutero will usually develop a favorite side, often disregarding one side. In the breech baby this may present as not having contact with the front of the body, or with the top and bottom half of the body.

Being asymmetric in infancy affects the integration of sight and balance with movement interfering with normal development of the core musculature.

The condition left untreated results in asymmetry in the developing child.

When we discuss scoliosis, there are two aspects to consider. One is that scoliosis develops and the other is the scoliosis that progresses. There are different theories as to why some children develop scoliosis; there is not a single cause. There are different theories why a scoliosis becomes aggressive and progresses into a more deforming condition. More to come on this.

What is important in the treatment of scoliosis is evaluation of the curves, optimizing function of the spine and working with exercises to reduce the curves and gain core strength and stability. Each child gets an individual program which is based on how their curve has or is developing. Another important aspect of managing scoliosis is nutritional supplements. Certain nutrients, D vitamin in particular, are critical for the developing spine. There is a higher risk for scoliosis in Scandinavia due to the northerly latitude. Under the section “näring och hälsa” are recommendations for supplementing D vitamin, both how much to take and during which months of the year.

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In children the size of the head is proportionally larger in reference to the body until puberty. Injuries sustained to the head and neck in infancy will affect a different area of the spine than during later childhood. The weight of the head is a strain on the neck. With that said a key message for children is to reduce strain on the neck by avoiding looking down for extended periods of time. We are seeing a rise in the incidence of screen related neck problems in children and adolescents which in Swedish is called ”Padnacke”. The message here is to keep screens at eye height, observe how your children use the different media and help them find a position where the sit up straight and have their head over their shoulders, gaze straight ahead. It may a help to use pillows in the lap to rest the arms on to raise screen height so the neck is not under strain. Check out the picutres on this site under ”ergonomi”. Another group of children who experience neck pain are those who are avid readers, play instruments and/or have prolonged static activities with their arms stretched out and unsupported. Sitting properly at a desk which is ergonomically adapted for the size of the child is important as well when doing homework. We recommend using the TV for films to reduce static strain on the eyes and the neck. Besides the neck, eyesight in children has been shown to be affected by prolonged periods of time looking at screens. Children are not looking using the eyes to look up and away nearly as much which has resulted in an increased incidence of myopia. The most vulnerable to neck pain are those who have had an injury early on to the head or neck. They tolerate less well when the neck is bent forward for sustained periods of time, over books or a screen. Good ergonomics at home and in school are important, but reducing screen time and increasing physical activity is critical for long-term optimal health of children.

Consultation with the World Health Organization recommending non-pharmacological alternatives for infants and children

As an expert in paediatrics and a faculty member for the European Academy of Chiropractic (EAC) within the European Chiropractic Union (ECU), I have worked to formulate a contribution to the EU consultation on paediatric regulation for the World Health Organization (WHO). The goal is to promote specific research and trials for drugs prescribed for children, rather than, as were the practice, extrapolating data from experiments on adults. Children and particularly infants are not miniature adults; most of the medications prescribed are not adequately researched for them. They differ in anatomy and physiology, so the response to medication depends on the maturity of their developing systems. This is why medication doses cannot just be downsized.

Our contributions have focused on alternative non-pharmacological interventions to be tried before medication is prescribed. We have seen examples of this with exercise being prescribed as medication. Last week the guidelines for physicians were published for treatment of low back pain and the headlines are: non-pharmacological, alternative treatment is recommended for back pain, among which is spinal manipulative therapy or chiropractic care. Chiropractic care is not just a quick maneuver, it is a package of care first assessing the problem as the spinal care specialist; treating biomechanical dysfunctions with any of a variety of techniques; instructing the patient in self-care, proper posture and ergonomics; and instructing in appropriate exercise to stabilize the injury.

This type of approach to a patients’ biomechanical health is appropriate at all ages and is part of the solution to avoiding chronic pain. The infant with a biomechanical problem due to in-utero constraint or a difficult delivery needs this type of early intervention to avoid permanent changes in how the brain interprets pain. For the geriatric patient’s quality of life, they need a biomechanical assessment and treatment to optimize functioning and learn exercises to keep them functional and prevent falling. Optimal biomechanical functioning is important for good health in all age groups.

Some of the suggestions recommended for addressing the cause of the problem and reducing unnecessary medication and the risks for adverse effects for the infant and child are as follows:

• Before pain medication is prescribed for otherwise healthy neonates, infants and children, an assessment by a spinal care expert should be performed to rule out the possibility of pain due to a biomechanical dysfunction that would be amenable to treatment. A short trial of care is appropriate with positive findings.

• For the otherwise healthy neonate, infant or child with persistent crying and/or any of the following symptoms: recurrent vomiting, stomach pain, eczema, audible mucous or coughing during expiration or constipation: a 3 week trial of milk protein free and soy protein free diet (for the breastfeeding mother and/or child).

• These milk, soy and gluten free formulas should be made available for families over the counter and at a comparable price to regular formulas.

For the following conditions:
• Treatment of GORD or reflux in the infant: before a trial of medication with proton pump inhibitor, the infant should have a 2 week trial of milk protein and so protein free diet to see if symptoms resolve.

• For children not meeting their growth curves: A 4 week trial of milk protein and soy protein free diet. For Scandinavian children and children testing positive for HLA-DQ8(2) positive, a 3 month trial of a gluten free diet should be tested.

• Constipation in the infant or child: a 3 week trial of milk protein and soy protein free diet be assessed before prescribing medication.

• In otherwise healthy children, presenting with back pain, neck pain or other joint pain, an assessment by a spinal expert and a trial of chiropractic care should be made available and assessed before prescribing medication.

One of the groups of children particularly vulnerable for injury to the developing skeleton is the athlete in preadolescence. The skeleton is actually weaker as it has its growth spurt and it is this period when young athletes are often exposed to an increase in training, both with respect to training intensity and duration. The spine as it undergoes growth is not as stable as the adult spine. It is vulnerable to high impact and to over-training, common causes of spinal injury. The injuries sustained are often lifelong with significant debilitating pain in adulthood. The increase prevalence of scoliosis in dancers and gymnasts is coupled to increased hours of high impact in the immature skeleton. The strive to become a winning team has become greater than ensuring good health among our young athletes. Recommendations are to avoid specializing to early. Train one sport per season and vary sports to minimize repetitive strain and to increase neuromotor skills. These recommendations are associated with fewer injuries and more balanced athletes.

Once an injury has been sustained, regardless of whether the child is an athlete or not, age appropriate rehabilitation is critical for a successful outcome. There are few practitioners with skills on this level. As experts in spinal health, we have focused in this area and are experts in the rehabilitation of the child athlete.

Interestingly, there are different groups of children who benefit from the basic core exercises which are fundamental to the rehabilitation program. Children with neurodevelopmental problems and children that are obese commonly lack normal movement strategies. Some children with neurodevelopmental disorders lack activation of the core prior to a movement. This results in movements that lack a smooth and coordinated rhythm. The goal with training is to teach these basic movement strategies so thse children can experience how to access these muscles.For the obese child, guidance is needed to learn normal movement strategies and appropriate training to reduce the strain on the load-bearing joints which can be a source of injury and disability later in adult life.

Hestbaek l, Jørgensen A, Hartvigsen J. A description of children and adolescents in Danish chiropractic practice: Results from a nationwide survey. JMPT;32(8)607-15.

Hestbaek L, Stochkendahl MJ. (2010). The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor’s new suit? Chiropractic & Osteopathy;18:15.Doi:10.1186/1746-1340-18-15.

Weber S, Miller J. (2008). Pharmceutical treatment for migraine prevention in children: Is there evidence to support its safety and efficacy? In: Conference and Research Symposium in Chiropractic Pediatrics, 18-20 April Austrailia. ICA Council on Chiropractic Pediatrics, 54.